Provider Demographics
NPI:1588876411
Name:BLACKMON, MICAH SHAWN (MD)
Entity type:Individual
Prefix:DR
First Name:MICAH
Middle Name:SHAWN
Last Name:BLACKMON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 102321
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2321
Mailing Address - Country:US
Mailing Address - Phone:770-801-2500
Mailing Address - Fax:770-803-2121
Practice Address - Street 1:775 POPLAR RD
Practice Address - Street 2:SUITE 160
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-8300
Practice Address - Country:US
Practice Address - Phone:770-400-4630
Practice Address - Fax:770-254-6069
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059045208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I348220OtherMEDICARE PTAN
FLAE672ZMedicare PIN